Intravenous thrombolysis in the elderly is facilitated by a tele-stroke network: A cross-sectional study

BACKGROUND

Data suggest that elderly patients have less favorable outcomes after ischemic stroke.

OBJECTIVE

To study the outcomes after intravenous tissue plasminogen activator (tPA) administration in elderly patients with acute ischemic stroke.

METHODS

Cross-sectional study using prospective collected patient data maintained via our "tele-stroke" network, which provides acute care in 29 community hospitals within our region from 2013-2015. Exposure of interest was age divided into >80 years (octogenarian) or younger. Outcomes of interest were rate of intravenous tPA administration, hemorrhagic transformation (ICH), in-hospital neurological deterioration, and poor outcome defined as a composite of hospital discharge to long-term care facility or death.

RESULTS

Mean age 67 ± 16 years, 57 % (743/1317) were women, and median (Md) NIHSS was 4 (Interquartile Range [IQR] 8). The rate of tPA was 20 % (267/1317). Compared to reported rates of tPA administration in the nation, our tPA rate exceeded the one from the literature (20 % v 3%, z = 2.83, SE = 0.04, p = .005). There were no differences in ICH or neurological deterioration. The octogenarian group had a higher proportion of poor-outcome (61 % vs. 23 %, p < 0.001) than the younger group but similar in-hospital case-fatality (25 % v 14 %, p = 0.09). Predictors of poor-outcome were age >80 (OR 4.9; CI, 2.0-12, p < .001) and α-NIHSS>9. (OR 8.7; CI, 3.5-20, p < .001).

CONCLUSION

Our data suggest that in our "tele-stroke" network, rates of tPA administration are higher than those reported in the literature and that this rate was not different in octogenarians compared to younger patients. Octogenarians were not at risk for ICH or neurological deterioration after tPA administration. However, octogenarians had a higher risk of poor outcome.

Intra-Arterial Chemotherapy for Retinoblastoma in Infants ≤10 kg: 74 Treated Eyes with 222 IAC Sessions

BACKGROUND AND PURPOSE

Intra-arterial chemotherapy for retinoblastoma has dramatically altered the natural history of the disease. The remarkable outcomes associated with a high safety profile have pushed the envelope to offer treatment for patients weighing ≤10 kg. The purpose was to determine the efficacy and safety of IAC infusions performed in infants weighing ≤10 kg with intraocular retinoblastoma.

MATERIALS AND METHODS

A retrospective chart review was performed for patients diagnosed with retinoblastoma and managed with intra-arterial chemotherapy.

RESULTS

The total study cohort included 207 retinoblastoma tumors of 207 eyes in 196 consecutive patients who underwent 658 intra-arterial chemotherapy infusions overall. Of these, patient weights were ≤10 kg in 69 (35.2%) and >10 kg in 127 (64.8%) patients. Comparison (≤10 kg versus >10 kg) revealed that the total number of intra-arterial chemotherapy infusions was 222 versus 436. Periprocedural complications were not significantly different (2 [0.9%] versus 2 [0.5%]; P = .49). Cumulative radiation exposure per eye was significantly lower in infants weighing ≤10 kg (5.0 Gym² versus 7.7 Gym²; P = .01). Patients weighing ≤10 kg had a greater frequency of complete tumor regression (82.6% versus 60.9%; P = .02). Mean fluoroscopy time was not significantly different (7.5 versus 7.2; P = .71). There was a significant difference in the frequency of enucleation (16 [21.6%] versus 52 [39.1%]; P = .01). Patients weighing ≤10 kg had greater number of aborted procedures (12 [5.4%] versus 7 [1.6%]; P = .01). On multivariate analysis, weight ≤10 kg was not an independent predictor of complications or procedure failure.

CONCLUSIONS

Intra-arterial chemotherapy in patients weighing ≤10 kg is a safe and effective treatment.

Pipeline Embolization Device in the Treatment of Recurrent Previously Stented Cerebral Aneurysms

BACKGROUND AND PURPOSE

The use of the Pipeline Embolization Device in the management of recurrent previously stented cerebral aneurysms is controversial. The aim of this study was to evaluate the efficacy and safety of the Pipeline Embolization Device in the treatment of recurrent, previously stented aneurysms.

MATERIALS AND METHODS

Twenty-one patients with previously stented recurrent aneurysms who later underwent Pipeline Embolization Device placement (group 1) were retrospectively identified and compared with 63 patients who had treatment with the Pipeline Embolization Device with no prior stent placement (group 2). Occlusion at the latest follow-up angiogram, recurrence and retreatment rates, clinical outcome, complications, and morbidity and mortality observed after treatment with the Pipeline Embolization Device were analyzed.

RESULTS

Patient characteristics were similar between the 2 groups. The mean time from stent placement to recurrence was 25 months. Pipeline Embolization Device treatment resulted in complete aneurysm occlusion in 55.6% of patients in group 1 versus 80.4% of patients in group 2 (P = .036). The retreatment rate in group 1 was 11.1% versus 7.1% in group 2 (P = .62). The rate of good clinical outcome at the latest follow-up in group 1 was 81% versus 93.2% in group 2 (P = .1). Complications were observed in 14.3% of patients in group 1 and 9.5% of patients in group 2 (P = .684).

CONCLUSIONS

The use of the Pipeline Embolization Device in the management of previously stented aneurysms is less effective than the use of this device in nonstented aneurysms. Prior stent placement can worsen the safety and efficacy profile of this device.

A single pipeline embolization device is sufficient for treatment of intracranial aneurysms

BACKGROUND AND PURPOSE

The Pipeline Embolization Device has emerged as an important treatment option for intracranial aneurysms. The number of devices needed to treat an aneurysm is uncertain and is the subject of vigorous debate. The purpose of this study was to compare rates of complications, aneurysm occlusion, and outcome in patients treated with a single-versus-multiple Pipeline Embolization Devices.

MATERIAL AND METHODS

One hundred seventy-eight patients were treated with the Pipeline Embolization Device at our institution. Patients were divided into 2 groups: a single-device group (n = 126) and a multiple-device group (n = 52).

RESULTS

There was no statistically significant difference between the 2 groups with respect to baseline characteristics except for age and aneurysm size (higher with multiple Pipeline Embolization Devices). Complications occurred more frequently with multiple (15%) versus a single device (5%, P = .03). In multivariate analysis, the use of multiple devices independently predicted complications. A similar proportion of patients achieved adequate aneurysm obliteration at follow-up in the single-device (84%) and the multiple-device groups (87%, P = .8). In multivariate analysis, age and follow-up time predicted obliteration. At follow-up, a significantly higher proportion of patients treated with a single device (97%) achieved a favorable outcome compared with those treated with multiple devices (89%, P = .03). In multivariate analysis, there was a strong trend for the use of a single device to predict favorable outcomes (P = .06).

CONCLUSIONS

Treatment with a single Pipeline Embolization Device provides similar occlusion rates with less complications and better overall outcomes. These findings suggest that a single Pipeline Embolization Device is sufficient for treatment of most intracranial aneurysms.

Coiling of large and giant aneurysms: complications and long-term results of 334 cases

BACKGROUND AND PURPOSE

Large and giant intracranial aneurysms are increasingly treated with endovascular techniques. The goal of this study was to retrospectively analyze the complications and long-term results of coiling in large and giant aneurysms (≥ 10 mm) and identify predictors of outcome.

MATERIALS AND METHODS

A total of 334 large or giant aneurysms (≥ 10 mm) were coiled in our institution between 2004 and 2011. Medical charts and imaging studies were reviewed to determine baseline characteristics, procedural complications, and clinical/angiographic outcomes. Aneurysm size was 15 mm on average. Two hundred twenty-five aneurysms were treated with conventional coiling; 88, with stent-assisted coiling; 14, with parent vessel occlusion; and 7, with balloon-assisted coiling.

RESULTS

Complications occurred in 10.5% of patients, with 1 death (0.3%). Aneurysm location and ruptured aneurysms predicted complications. Angiographic follow-up was available for 84% of patients at 25.4 months on average. Recanalization and retreatment rates were 39% and 33%, respectively. Larger aneurysm size, increasing follow-up time, conventional coiling, and aneurysm location predicted both recurrence and retreatment. The annual rebleeding rate was 1.9%. Larger aneurysm size, increasing follow-up time, and aneurysm location predicted new or recurrent hemorrhage. Favorable outcomes occurred in 92% of patients. Larger aneurysm size, poor Hunt and Hess grades, and new or recurrent hemorrhage predicted poor outcome.

CONCLUSIONS

Coiling of large and giant aneurysms has a reasonable safety profile with good clinical outcomes, but aneurysm reopening remains very common. Stent-assisted coiling has lower recurrence, retreatment, and new or recurrent hemorrhage rates with no additional morbidity compared with conventional coiling. Aneurysm size was a major determinant of recanalization, retreatment, new or recurrent hemorrhage, and poor outcome.

Endovascular treatment of posterior communicating artery aneurysms with oculomotor nerve palsy: clinical outcomes and predictors of nerve recovery

BACKGROUND AND PURPOSE

ONP is a well-known presentation of PcomA aneurysms. Reports on recovery of ONP with endovascular coiling have been limited to small case series. We assessed the safety and efficacy of endovascular therapy in a series of PcomA aneurysms with ONP.

MATERIALS AND METHODS

We reviewed 37 patients with ONP who underwent endovascular treatment in our institution between 2005 and 2011. Published studies were also reviewed to determine the overall rate of ONP recovery with endovascular therapy.

RESULTS

Nineteen patients (51.4%) presented with complete ONP, and 18 (48.6%), with partial ONP. Conventional coiling was performed in 31 (83.8%) patients; stent-assisted coiling, in 4 (10.8%); and balloon remodeling, in 2 (5.4%). There was 1 (2.7%) procedural complication (a transient thromboembolic event). Twenty-seven (73%) patients were treated within 3 days from symptom onset. At the last available clinical follow-up, ONP resolution was complete in 14 (37.8%) patients and partial in 19 (51.4%). Only 4 (10.8%) patients showed no signs of nerve recovery. In multivariate analysis, partial ONP and longer follow-up durations were predictors of complete nerve recovery. Treatment timing, type of endovascular embolization, subarachnoid hemorrhage, and initial degree of aneurysm occlusion were not predictors of nerve recovery. Of 169 patients reported in the literature (including ours), ONP resolved completely in 73 (43.2%) patients and partially in 73 (43.2%).

CONCLUSIONS

Endovascular therapy is a safe and highly efficient alternative to surgical clipping for PcomA aneurysms with ONP.

Superior hypophyseal artery aneurysms have the lowest recurrence rate with endovascular therapy

BACKGROUND AND PURPOSE

Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms.

MATERIALS AND METHODS

Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011.

RESULTS

We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6-60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization.

CONCLUSIONS

SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.